Taking Your Improvement to the Next Level

March 3, 2005

Chuck DeBusk and Ben Miles

Real-World Usage of Six Sigma, Lean and Change Management Techniques in Healthcare

2

Objectives

Learning valuable lessons from the successes and failures involved with creating a project funnel

Distinguishing between various methods and tools, and understanding when to use alone or in combination

Exploring actual case study examples

Acquiring tips on engaging all levels of the organization in driving change (executive, physician, staff, etc.)

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St. John Health – Who We Are

• St. John Health comprised of 8 hospitals and over 100 medical facilities in southeast Michigan

• History in Detroit area from 1844

• Guided by our Mission; Shaped by our Values Committed to providing spiritually centered, holistic care Sustain and improve the health of individuals in the communities we

serve, with special attention to the poor and vulnerable

• SJH – Vision for the Future To provide the highest quality patient care experience each time,

every time

4

Performance Solutions

GE People GE Discipline150 Top

Clinical and Business Talent

GE Tools Lean

Six SigmaCAP

Work-OutTM

FocusedFact-Based

Values-Driven

Pragmatic

Applying GE’s Proven Approach to Transform Healthcare

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Perspective on the Basics

“Gentlemen, this is a football…”

Vince Lombardi(Stated at the beginning of training camp each year.)

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How is Six Sigma organized at St. John

System COO directs deployment of Six Sigma

System MBB’s directly report to the System COO

Steering Committee made up of COO, CMO, CFO, EVP-HR, EVP-OE, System VP of Quality, and MBBs

Each hospital has an Executive Sponsor (Champion) with a reporting relationship to the System COO in addition to the Hospital CEO

Hospital BB’s directly report to Executive Sponsors with dotted lines to System MBB’s

System COO

MBB’s Executive Sponsor

Hospital BB’s

SteeringCommittee

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ProjectBrainstorming

ProjectScoping

Executive CouncilReview / Approval

Value Stream Map& Data Pull

DMAIC

Project ExecutionFinance

Prelim Review

Finance Review& Validation

Project Sponsor &Team Selection

Operations/StrategicPlanning

FinanceQuality 6

Mission

Six Sigma Project Selection Cycle

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How do we start creating a funnel?

ReadTranscribe

Results Available

Level 1Key Business Metric Length of StayLength of Stay

Level 2 BusinessProcesses

Feeder to BedFeeder to Bed ProvideProvideInpatient CareInpatient Care

Discharge Planning Discharge Planning ProcessProcess

Execute Discharge Execute Discharge OrderOrder

Level 5Detailed Subprocess Map

Lab OrdersImaging Order TAT

Pharmacy Orders

Level 4High LevelProcess Map

Doc Order

Schedule Exam/Study

Prep Patient

Patient Transport

Complete Exam/Study

Nursing Care

Order Turn Around Time

Physician Referral Process

Practice Patterns

Level 3High-LevelProcesses

Where the pain is

or Focus Areas

Where the

projects are

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The Approach

IdentificationIdentification

ScopingScoping

SelectSelect

Identification• Key metrics/line of sight• Financial Opportunity Estimate• Sponsorship • Conflicts/other efforts

Select• Determine mix of projects & Work-Outs• Choose project sponsors• Identify team members• Set tentative goals

Scoping• Data Analysis• Process mapping • Calculate financial opportunity• Identify project potential

Select:Determine array of projects and Work-Outs that can be done in the next 6 months. Assure that array of projects and Work-Outs are aligned with organizational goals

Scoping: Break down a Focus Area to understand the many specific processes, sub-divisions of the business and/or segments that drive the performance of the Focus Area. Uncover multiple potential “projects”, or processes requiring improvement.Determine specific financial opportunity

Identification: Determine focus areas* or “sources of pain”High level evaluation of potential, support, conflicts.

* Focus Area: An area of the business, a high-level process, a department or function, or an important performance metric that has potential to be improved. Focus areas typically yield more than one Work-OutTM and/or Six Sigma“project”.

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Common Characteristics of Six Sigma Project*

While each healthcare organization has specific needs and issues to resolve, the most successful Six Sigma projects usually share common characteristics:

• Feasibility from a resource and data standpoint • Unambiguous parameters and clearly defined goals • Alignment with critical hospital issues and strategic initiatives • Provision of visible benefits for the customer • Inclusion of a Green Belt or Black Belt working within the project area • Ability to show measurable improvement • Linkage with other projects for a combined effect • Personal connection for the project leader

*Source: Guidelines for Six Sigma Healthcare Project Selection by Wendy Catalani-Davies and Carl Vieth – iSix Sigma Healthcare

Admittance to the funnel requires these characteristics

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Project Contact

Finance Contact

Recommendation Why/Why not? Estimated Financial Impact

Robust Data System

Ease of Implem-entation

1 IP Discharge E Yoder S Maxwell Yes

Big $; however, difficult from data and behavioral standpoint H N L

2 IP Discharge P Lamb S Maxwell YesSolid $ and data system available. M Y H

3 IP Transfer

D Thomas (IT) - data from Invision S Maxwell Pending

Further scoping needed to validate data system and $. M Y (?) L/M

4 LOS C Trembath S Maxwell Yes

Lines up nicely with strengths of Six Sigma project. Good $. M Y M

5 Readmission M Klobucar S Maxwell Pending

Readmit rate 7.5% (15 day); 10.7% (31 day). Need to validate $. M Y M

Utilization

6Blood Bank Utilization by doc B Herschman S Maxwell Yes

Potential for decent return with minimal, targeted resistance. L/M Y M

7Hospitalist - LOS by doc E Yoder S Maxwell Pending

New group recently in place. Metrics improving - wait. L Y H

8Monitored bed utilization D McLean S Maxwell Yes

Strong financial impact. Potential for M or H resistance H Y L/M

Utilization in targeted areas (Onc, Card, etc)

Project NameIn Preparation of Project Selection MeetingTo Be Filled In After Project Brainstorming Meeting

Project Description

Improve efficiency and discharge IP earlierBed clean / TAT for Housekeeping. Use of Bed Tracking Mitigate # of IP transfers between departments

LOS by DRGReadmission to hospital within 15 & 31 days

St. John Health - Providence Hospital Project Identification

Financial Impact: L < $100K, M $100K - $500K, H > $500K

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Project Identification/Funnel Screen Example

Project Description/Project Name Data Requirements Metric(s) Impacted hospitals Project ROICompeting Priorities

Team Availability Sponsor

Alignement w/strategic plan ROI Value

Operating Room Thruput

1st Case start informationTurn Around TimeOR UtilizationBlock UtilizationCost Per CaseVolumes/Day/Month

Cases/Day Hospital A TBD 3 3

LOS Reduction (initial focus on outliers)>$50K ReportLOS by DRG

Dollars in Outliers?

Hospital B TBD 3 3

Revenue Cycle

Days in ARDenialsRegistration ErrorsCo-pays/Con-Insurance CollectionsCharge CaptureWrite-offs/collection agency

Days in ARDenialsPOS Collections

System TBD 7 7

Registry Usage (Radiology & Nursing)

Staffing/hourRegistry costs/day/monthOvertime/day/monthDepart/Registry usage

System TBD 3 7

Test Edits (Revenue Cycle - prior to bill drop)

Any/all test edit data Days in AR Med Group TBD 3 3

Call Centercall abondanment ratecall lengthwait times

Med Group TBD 3 1

Inventory Reductions & Supply Standardizations

TBD

Inventory CostsSupply Cost/Case

Hospital B TBD 1 1

Ancillary Service Utilization TBD System TBD 1 1

Staffing Variances buget vs actual costsVariance (Budget-Actual)/Mo

Hospital C 7 3

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Model for Project Generation - A Better Way?

Operations Plan

Strategic Plan

Project ScopingWhat is the right operational area for a project?

DMAIC

Project Conclusion

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Common Problems in Creating a Funnel

Little or no executive involvement• Fear or the “No problems here” syndrome• Six Sigma (quality / process improvement) is someone else’s

responsibility• No personal connection

Projects are driven from the bottom up

Not enough time to scope properly

Not truly a Six Sigma project (Classification)

No clear line of sight to organizational metrics that are important to the executives

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Lead Time Defect Rate

M Work-OutTM

“Expert Driven” “Data Driven”

H

Type of ChallengeN

on

Val

ue

Co

st R

edu

ctio

n

Six Sigma

Lean“Waste Elimination”

[Months]

[Weeks]

Lean Six Sigma

Uncommon Tools for Healthcare Challenges

Lean + Six Sigma = Speed + QualityLean + Six Sigma = Speed + Quality

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Comparison of Lean and Six Sigma

  Lean Six Sigma

Goal Create flow and eliminate waste Improve process capability and eliminate variation

Application Primarily manufacturing processes* All business processes

Approach Teaching principles and "cookbook style" implementation based on best practice

Teaching a generic problem-solving approach relying on statistics

Project Selection

Driven by Value Stream Map Various approaches

Length Of Projects

1 week to 3 months 2 to 6 months

Infrastructure Mostly ad-hoc, no or little formal training

Dedicated resources, broad-based training

Training Learning by doing Learning by doing

Retrieved from: www.isixsigma.com

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Case Study - ED Throughput

Value Stream Map illustrates various “flows” within the ED

Bottlenecks are flagged for analysis to determine whether Lean opportunities are present

Flow issues Value Analysis

Concurrently, VOC data is collected to determine direction for formal efforts in a Six Sigma project(s)

♦ The appropriate use of Lean and Six Sigma will allow maximum efficiency and effort to be realized

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Case Study - ED Throughput

Lean is predicated upon the identification and elimination of waste

7 Wastes addressed by Lean1. Multiple processes2. Incomplete information3. Communication gaps4. Waiting5. Incorrect data6. Lack of standards7. Unnecessary approvals

Technique used = 5S Red TagSort-Standardize-Simplify-Sweep-Sustain Express Care Mini Kaizen

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Case Study - ED Throughput

Six Sigma employs a data-driven methodology to systematically break a problem down into key drivers, based upon various statistical analyses

Estimated Effects and Coefficients for D2D (coded units)

Term Effect Coef SE Coef T PConstant 87.34 2.547 34.30 0.000Express Care 35.56 17.78 2.547 6.98 0.000X-Ray 36.06 18.03 2.547 7.08 0.000Bed Open -37.81 -18.91 2.547 -7.42 0.000Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025Express Care*X-Ray*Bed Open 5.19 2.59 2.547 1.02 0.338

S = 10.1865 R-Sq = 96.87% R-Sq(adj) = 94.12%

Analysis of Variance for D2D (coded units)

Source DF Seq SS Adj SS Adj MS F PMain Effects 3 15979.9 15979.9 5326.6 51.33 0.0002-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.0003-Way Interactions 1 107.6 107.6 107.6 1.04 0.338Residual Error 8 830.1 830.1 103.8 Pure Error 8 830.1 830.1 103.8Total 15 26489.4

Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open

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Case Study - ED Throughput

Dual approach of Six Sigma and Lean enabled achievement of the goal for this project

Accomplishments Mean reduced by 25 min (38%) Std Dev reduced by 17 min (38%) Range reduced by 46% Z-score improved by 0.44DPMO reduced by 158,333 Flow improved with elimination of Non-Value Added process steps Standards created to sustain change Financial Impact ~ $1 million

Phase

95% Bonferroni Confidence Intervals for StDevs

Measure

Control

50454035302520

Phase

Data

Measure

Control

250200150100500

F-Test

0.002

Test Statistic 0.37P-Value 0.000

Levene's Test

Test Statistic 9.67P-Value

Test for Equal Variances (Measure-Control)

250

200

150

100

50

0

250

200

150

100

50

0

Measure Control

Individual Value Plot of Measure Data, Control Data

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Case Study – Sustaining Change

(Week of)

Sam

ple

Mean

10/ 2510/ 1810/ 1110/ 49/ 279/ 209/ 139/ 68/ 30

80

60

40

20

0

__X=42.43

UCL=81.88

LCL=2.97

(Week of)

Sam

ple

Ran

ge

10/ 2510/ 1810/ 1110/ 49/ 279/ 209/ 139/ 68/ 30

160

120

80

40

0

_R=68.4

UCL=144.6

LCL=0

Xbar-R Chart of Door to Doc Time

Door to Doctor Time

R1 (04-04) R4 (09-04) 12-04

Mean 64.3 min 39.8 min 42.4 min

St Dev 44.7 min 27.7 min 28.6 min

LWBS 2.0% 1.0% 1.2%

ZST 1.91 2.35 2.22

Project Opportunities• Increase Patient Satisfaction (Press Ganey)

12-03 09-04 ED Top Box 51.6 53.4

• Financial Impact Hard Dollar Opportunity = $948,063 Based upon 444 visits & 186 admits

Captured 175 visits & 40 admits YTD

• Throughput / ED Volume Nov YTD Visits over budget by 744

(+1,043 PY) Nov YTD Admits over budget by 497

(+516 PY) FY 2004 Nov YTD LWBS% = 2.1% vs

1.2%

Lessons Learned

+ Associate participation Need all “vital” Xs forand empowerment complete sustainability

Consistent message and Heavy volume and shiftfocus to IP strains system

Six Sigma works

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Wave II – The Cycle ContinuesE D T hro ug hp ut

(D isp o to E D D isch arg e)

K a thy RyanP ro je ct S p o nsor

M K e lly -N icho lsG ree n B e lt

L eadP ro ce ss O w n er

S tev e M cG rawG e org e H ig heY e llo w B e lts

Je n C arp en te rR o se L ow ryY e llo w B e lts

L isa P lecha

Y e llo w B e lt

B e n M ilesS ix S igm a B lack B e lt

E D T hro ug hp u t(D isp o to IP A d m is sio n )

P r is c illa L am bP ro je ct S p o nsor

Ju lie B e llL y nn C h ie saG ree n B e lt

K a tr ina S v o bo daD e n ise M cLe an

Y e llo w B e lts

Ja n H u gh esW e nd y C o leY e llo w B e lts

S u e T uck erC . T re m b a th , M D

Y e llo w B e lts

B e n M i lesS ix S igm a B lac k B e lt

ED T hroughput(R adio logy P rocedure T AT)

M ar i lou ise R iskaP ro je ct S p o nsor

M a rty Ha r r is, M DG ree n B e lt

L ead

R o g er G o n d a, M DY ello w B e lt

P ro ce ss O w n er

C h ris t ine C ro skeyS e rb a n D utica

S ue B ir liY e llo w B e lts

L isa B ur ryD e n ise H o hn er

G e ra rd Surm an n, MDY ello w B e lts

B e n M ilesS ix S igm a B lack B e lt

Tied to improvementstrategies of Phase IDoor-to-Doc Project

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Engaging Executives at All Levels

Engagement as a function of knowledge

Engagement as a function of accountability

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Engagement as a Function of Knowledge

Not all executives created equal (Power/Influence tool)

Tools for increasing knowledge:• Six Sigma Awareness Day

• Executive Briefings

• Project Reviews

• Articles in hospital newsletter

• Posters

• Medical staff meeting presentations and project recaps

• Physicians on project teams (Green Belts or Team Members)

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Engagement as a Function of Accountability

Organizational level goals and expectations• ROI or Savings• Increases in patient/customer satisfaction• Tied to strategic or operational goals and accountability

Executives responsible for moving metrics• Black Belts responsible for solutions / project sponsors

accountable for results• Project Sponsors lead Report-Outs• Executive Sponsors (Champions) responsible for

organizational metrics and Six Sigma’s contribution

For questions regarding the presentation contact:

Chuck DeBusk, GE Healthcare

763 561 9263

charles.debusk@med.ge.com

Ben Miles, St. John Health

248 849 5823

benjamin.miles@providence-stjohnhealth.org